Medical Management of ectopic pregnancy with Methotrexate

The risk associated with treating being treated medically is that the medicine may not work as the cells of the ectopic pregnancy may continue to divide, which could result in there still being a need for surgery. Success rates do vary depending on the circumstances in which methotrexate is given. Studies report success rates of 65-95%. Success rates tend to be higher with lower serum hCG levels. Your doctor should be able to tell you the success rate of methotrexate in their unit. Doctors can tell if the specialised cells of a pregnancy that produce the hCG hormone are still dividing because the hCG level will continue to rise and not fall. This will be monitored through blood tests.

Occasionally, an ectopic pregnancy can rupture despite low hCG levels. Your hospital should have given you a number to contact for health advice if you feel that anything is changing, or you will have been told to report to the Accident and Emergency (A&E) department. If you have not been told what to do and need to speak to someone ring the hospital department which is treating you or the NHS 111 Service by dialling 111.

Women with ectopic pregnancies in a Fallopian tube who are treated with methotrexate:

• require a second dose of methotrexate in 14% of cases (14 out of 100 women); and 
• require surgery in 29% of cases (29 out of 100 women), despite treatment with methotrexate.

The most common side effects of methotrexate are:

• Cramping abdominal (tummy) pain is the most common side effect, and it usually occurs during the first 2 to 3 days of treatment. Because abdominal pain is also a sign of a ruptured ectopic pregnancy, report any abdominal pain to your health professional;
• Fatigue – a number of women feel very tired and are shocked by the sheer exhaustion that they encounter during treatment;
• Vaginal bleeding or spotting;
• Nausea, vomiting, and indigestion;
• Light-headedness or dizziness – Again, because this is also a sign of a ruptured ectopic pregnancy, please report it to your health professional;
• A numb or sore bottom from the injection.

Other rarer side effects from methotrexate treatment for ectopic pregnancy, include:

• Skin sensitivity to sunlight
• Inflammation of the membrane covering the eye
• Sore mouth and throat
• Temporary hair loss
• Severe low blood counts (bone marrow suppression)
• Inflammation of the lung (pneumonitis)

This method of treatment is more suitable for some than others and is more likely to be successful in the following circumstances:

• You are in good health
• Your Fallopian tube has not ruptured
• Your hCG level is low enough (your hospital will probably have a level above which this method will not be used)
• There is no significant abdominal bleeding

Because it does not entail an operation, this method has a particular advantage over surgery if:

• You have other medical problems that may increase the risks of a general anesthetic
• If you have adhesions in the abdomen or pelvis (as a result of previous surgery or infection)
• The ectopic pregnancy is situated in the neck of the womb or as the Fallopian tube enters the womb

Treatment of ectopic pregnancy with methotrexate is not appropriate if you suffer from any of the following conditions:

• An ongoing infection
• Severe anemia or shortage of other blood cells
• Kidney problems
• Liver problems
• Active infection
• HIV/AIDS
• Peptic ulcer or ulcerative colitis

You should stop taking any vitamins, minerals, or other medicines unless you have been told by the doctors treating you to continue with them, as some interfere with the effects of methotrexate. It is particularly important that you do not take any folic acid supplements and avoid foods enriched with folic acid until your doctors are sure that the drug has worked and hCG hormone level has returned to non-pregnant.

You should not do any heavy lifting or housework until the hCG levels are dropping consistently and should only undertake gentle exercise, such as walking, until the hCG (pregnancy hormone) is at non-pregnant level.

You should avoid sexual intercourse until your hCG is down to non-pregnant level.

Most people take time off from work initially and do not return to work for at least two weeks while the treatment begins to work.  Our website has information about ectopic pregnancy and the workplace.

In the first week, it is important to avoid pain killers which fall into the NSAID group such as ibuprofen. The preferred painkiller is paracetamol.  

You should refrain from drinking alcohol until hCG has fallen to a non-pregnant level and not drink alcohol for a few weeks after that.

Below are links to further information on physical recovery and emotional recovery after an ectopic pregnancy.

This usually takes a few weeks. According to a study, for women with ectopic pregnancies in a Fallopian tube who are treated with methotrexate (with hCG of 1000–5000 IU/L before treatment), it takes an average of 28 days for the ectopic pregnancy to resolve (when medical treatment is successful).

Although you may be eligible for methotrexate, the use of methotrexate for treatment of ectopic pregnancies across the UK is still varied. It may be that in one authority they use it and in the next, they do not. The decision ultimately lies with your medical team within the health authority you are under, but you can make your wishes clear and ask to be assessed by a unit that does use methotrexate.

If you would like methotrexate to be considered as an ectopic pregnancy treatment in your case, you are within your rights to ask to be referred to a unit where it is available. You should ask to be referred to a consultant within the Primary Care Trust who can assess your suitability for this kind of treatment or on to another treatment centre.

If you need any help with this, you need to contact the Patient Advice and Liaison Services (PALS) at the hospital where you are being treated. They can help you locate an assessment or new consultant if you need to.